Barriers and Facilitators to Morphine Prescription Among Clinicians in Uganda: A Qualitative Study at Mildmay Uganda

Barriers and Facilitators to Morphine Prescription Among Clinicians in Uganda: A Qualitative Study at Mildmay Uganda | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers and Facilitators to Morphine Prescription Among Clinicians in Uganda: A Qualitative Study at Mildmay Uganda Collins Ankunda, Sharon Namasambi, Brendah Kyomuhangi, Elizabeth Namukwaya This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7240173/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Pain management is a critical component of palliative care, particularly for HIV/AIDS and cancer patients. Despite oral morphine being an essential medication for treating moderate to severe pain, its accessibility and utilization remain suboptimal in many resource-limited settings. This study explored the barriers and facilitators to morphine prescription at Mildmay Uganda (Mug) to provide actionable insights for improving pain management practices. Methods: A qualitative study design was employed, involving semi-structured interviews with clinicians. 11 clinicians were purposively sampled based on their experience with morphine prescription and administration between March to April 2016. Data were analyzed thematically to identify key barriers and facilitators influencing morphine use in clinical practice. Results: Three primary barriers to morphine use were identified: opiophobia, knowledge gaps, and legal restrictions. Opiophobia was driven by concerns about addiction and adverse effects, particularly in home-based care settings. Knowledge gaps were highlighted among newly recruited staff and those without formal training, leading to inconsistencies in dosing practices. Legal restrictions, including limited prescriber authorization, further constrained access to morphine, particularly in community-based care. A key facilitator was the strong clinician consensus on morphine’s effectiveness in pain management, which enhanced confidence in its use and encouraged broader adoption in clinical practice. Conclusion: While clinicians acknowledge morphine’s effectiveness in pain relief, its use is hindered by opiophobia, knowledge gaps, and restrictive policies. However, strong clinician consensus on its benefits enhances confidence in prescribing. Targeted training and continuous medical education (CME) are essential to addressing misconceptions and improving competency. Strengthening policies to expand prescriber roles and integrating structured CME into routine practice can enhance clinical outcomes, reduce disparities, and ensure equitable access to pain relief, particularly in resource-limited settings. Morphine prescription Pain management Barriers and facilitators Uganda Introduction Pain management is a critical component of medical care, particularly for individuals living with HIV/AIDS(PLWH), where effective pain relief can significantly improve quality of life[ 1 ]. Globally, up to 83% of people living with HIV (PLWH) experience moderate to severe pain, particularly in advanced stages of the disease, due to the direct effects of HIV, opportunistic infections, cancers, or antiretroviral therapy side effects. Despite this high burden, only 21–53% receive opioid prescriptions[ 2 – 4 ]. Although pain is widely recognized as a major concern in people living with HIV/AIDS, it often remains underdiagnosed and inadequately treated, particularly in resource-limited settings such as Uganda [ 1 , 2 , 5 ]. Oral morphine, classified as an essential medicine by the World Health Organization (WHO), is the cornerstone for managing moderate to severe pain in palliative care[ 6 ]. Studies have demonstrated that morphine can be provided effectively, safely, and affordably, even in low-income settings[ 7 ]. Uganda has been recognized as a leader in palliative care in Africa, with innovations such as nurse-led morphine prescription and the integration of palliative care into its national health policy[ 8 – 10 ]. However, the government’s reported opioid consumption remains critically low, meeting less than 10% of the estimated need [ 11 ]. This gap highlights systemic challenges that hinder the prescription and availability of morphine, leaving a substantial number of patients in pain without adequate treatment. Studies done on morphine prescription have shown health workers’ reluctance to prescribe morphine as a significant barrier to its use[ 5 ]. Factors contributing to this reluctance include fears of side effects such as respiratory depression and addiction, limited training in opioid use, bureaucratic hurdles, and stigmatization of morphine as a “last-resort” treatment for the terminally ill[ 12 , 13 ]. These barriers are compounded by systemic challenges, including restrictive government policies, inadequate supply chains, and a shortage of trained prescribers. For instance, despite training efforts, many facilities lack accreditation to stock and dispense opioids, resulting in significant unmet needs among patients[ 11 ]. Despite Uganda's efforts to enhance morphine accessibility through expanded prescriber training and integrating palliative care into its health framework, many patients still endure unrelieved pain, reflecting global challenges in addressing under-treatment in HIV and cancer care[ 10 ]. Staff shortages, particularly in rural areas, limit access to trained providers, leaving many patients without adequate pain relief [ 14 ]. Informal discussions with clinicians at Mildmay Uganda revealed persistent hesitancy in prescribing morphine, despite training, with only seven patients receiving it over three months. This contrasts sharply with the estimated need among people living with HIV/AIDS at the facility. Understanding barriers and enablers to morphine prescription is crucial for improving pain management, addressing disparities, and enhancing opioid use in low-resource settings. These findings contribute to the global agenda for equitable palliative care by informing strategies to overcome reluctance, improve access to essential pain medications, and advance pain relief for underserved populations. Methodology Study Design This study employed a qualitative research design using thematic analysis to explore factors influencing morphine prescription among clinicians in Uganda, with a focus on Mildmay Uganda. The approach allowed for in-depth exploration of clinicians' experiences, concerns, and practices related to morphine use in the context of HIV care. Study Area Mildmay Uganda, established in 1998, is one of the leading HIV care and treatment facility in Uganda, serving as both a health provider and a research institution. The organization provides comprehensive HIV prevention, care, treatment, training, and research services in central Uganda. This study focuses on Mildmay Uganda, a prominent HIV care provider, which manages approximately over 5,000 patients monthly[ 15 ]. Study Population This study targeted clinicians actively involved in patient review and treatment at Mildmay Uganda. Participants included two specialists, seven medical officers, and two clinical officers who provided informed consent. Selection criteria focused on clinicians with prior training in morphine prescription and direct prescribing roles. However, those who met the criteria but were unavailable on the interview day were excluded. Sampling Techniques Purposeful sampling was employed to select participants who had relevant knowledge of morphine and were authorized to prescribe it. Specifically, the study focused on medical officers, clinical officers, and nurses who had completed a morphine prescriber’s course, ensuring they had the necessary understanding of how morphine works and when it is appropriate to prescribe. Recruitment continued until data saturation was achieved, where no new themes emerged from the data. The target sample size was 15 participants; however, the adequacy of the sample size was determined by the principal of data saturation rather than a fixed number. The study reached saturation with 11 participants, at which point no new themes emerged during data collection. Data Collection Data collection was conducted between March and April 2016 using a semi-structured interview guide developed in English by the study team. The guide was reviewed and refined based on feedback from the study supervisor and the ethical committee to ensure scientific rigor. Reliability was strengthened through a pilot study involving three different cadres of healthcare workers at Mildmay Uganda, with revisions made based on their feedback. The interview guide focused on key issues, including barriers to morphine prescription and associated challenges, allowing for a flexible yet structured exploration of participants' views and experiences. Open-ended questions with prompts facilitated in-depth and comprehensive responses, encouraging clinicians to freely express their concerns, fears, and insights regarding morphine use. Each respondent was assigned a unique identifier (R1–R11) to ensure confidentiality. To ensure anonymity and minimise identification bias, respondents were interviewed in a random sequence. Notably, all eleven clinicians accepted the invitation to participate, reflecting a shared willingness to discuss morphine use and its implications. Data Analysis The study team consisted of four members, with two interviewers conducting the interviews (one to interview and the other to take notes) and two analysts leading the data analysis process. Thematic analysis was conducted manually. Transcripts were reviewed in a cyclical and reflexive process to ensure a thorough examination of the data. Audio recordings were first cross-checked against field notes to verify accuracy and completeness before transcription. Transcripts were then transcribed verbatim in English and independently reviewed by the two analysts to identify emerging themes. Each analyst developed a thematic framework separately, and the final themes were refined through the integration of these frameworks. This process allowed for cross-validation and reduced individual interpretation bias. To ensure data integrity and minimize human error, results at each stage of analysis were checked against the study’s research questions. The two interviewers also cross-validated the data to further enhance credibility. Separating the roles of data collection and analysis and incorporating cross-checking mechanisms, the study minimized subjectivity and optimized the reliability and validity of its findings. Results Eleven respondents participated in this study, including two specialists who also served as heads of both adult and paediatric clinics, seven medical doctors, and two clinical officers. All of the respondents had served as clinicians for more than 2 years as shown in Table 1 below Table 1 Participants’ characteristics Number Unique Identifier* Duration in Service in years Date of interview 1 R1 12 9th March 2016 2 R2 08 9th March 2016 3 R3 02 9th March 2016 4 R4 04 9th March 2016 5 R5 03 9th March 2016 6 R6 06 9th March 2016 7 R7 04 9th April 2016 8 R8 05 6th April 2016 9 R9 02 6th April 2016 10 R10 04 7th April 2016 11 R11 05 7th April 2016 *Note: “R” refers to the respondent, and the number denotes the corresponding interview. Thematic analysis of the in-depth interviews revealed three major themes: knowledge gaps, opiophobia, and legal restrictions. These themes encapsulate the key barriers and facilitators clinicians encountered in prescribing and administering oral morphine as presented in Table 2 below. Table 2 Themes and Subthemes Theme Sub-themes Knowledge gap 1. Inadequate Training on Morphine Prescription 2. Uncertainty in Dosing Opiophobia 1. Risk of addiction 2. Abuse of Opioids Legal restrictions 1. Restrictive Prescribing Regulations 2. Lack of prescription guidelines in special populations Staffing Gap 1. Workload 2. Failure to Assess Pain Perceived Effectiveness of Morphine 1. Rapid Pain Relief 2. Essential Role in HIV related pain management. Knowledge gaps Most respondents identified inadequate training as a major barrier to morphine prescription, emphasizing the need for additional training to enhance healthcare workers' competency and optimize morphine use. One of the respondents remarked: “I think the challenge is people, many people have not been trained or probably they don’t have the right information, probably they don’t know how to use it. They may be prescribing 8 hourly or 6 hourly instead of 4 hourly, but otherwise, I feel that maybe that’s the major barrier to morphine use. But otherwise, it’s ok for me if used for the right purpose and properly, the right dose. (R5) Additionally, respondent R6 highlighted gaps in training, particularly for newly recruited staff: ‘Maybe with the new staffs who we have not yet trained… yeah, they might have different perceptions.’ (R6) While many clinicians cited inadequate training as a barrier to morphine prescription, some did not share this concern. One respondent highlighted the availability of Continuous Medical Education (CME) sessions, which offer regular learning opportunities. ‘I should not say often we don’t often get it (training), but we have CMEs weekly, and if a topic came up regarding medication of a patient that entails morphine, normally we share information about morphine and other opioid treatment.’ (R1) The respondent further suggested a practical approach to improving knowledge and practice among colleagues: ‘Maybe a way forward for colleagues to be knowledgeable is to have a case presentation on how different colleagues have managed pain because it is usually not common.’ (R1) Legal restrictions Respondents identified key barriers to morphine prescription, including restrictive prescribing regulations, the absence of clear guidelines for special populations such as people living with HIV (PLWH), and inconsistencies across existing prescribing guidelines. One respondent remarked: "Some guidelines might not allow nurses to prescribe, yet they are the ones conducting outreaches! For example, in organizations that provide outreach services to critically ill patients, I think they just need to be empowered to prescribe morphine." (R7) Similarly, respondent noted: "There are some nurses who have been trained on the ward, but they can only administer an initial dose. The doctor then has to step in and prescribe." (R6) Regarding morphine prescription for special populations, particularly malnourished children living with HIV, a respondent from the paediatric department raised concerns about the standard morphine dose of 0.2 mg/kg body weight, questioning its appropriateness for this vulnerable group. The respondent noted: "That dose of 0.2... is not favourable at all. The universal dose of 0.2 mg/kg oral morphine really does not suit malnourished children. I am not sure whether there are alternative guidelines specifically addressing morphine prescription in malnourished patients." (R3) Opiophobia. Respondents highlighted concerns about addiction, opioid misuse, and other side effects as key barriers to morphine prescription. One respondent expressed particular concern about prescribing morphine to outpatients, emphasizing the risk of addiction due to potential non-adherence to prescribed dosages. One respondent stated: "What I fear most is addiction, especially for outpatients. If you prescribe morphine, say a bottle, and instruct them to take 5 mL, they might go home and take 10 mL instead, knowing it provides relief. Over time, as they increase the dose, they risk becoming addicted and may seek it from other sources." (R2) Similarly, another respondent from the adult outpatient clinic highlighted concerns about respiratory depression as a serious adverse effect: "What we fear most with morphine is respiratory depression, primarily when someone receives a higher-than-normal dose. However, I have occasionally seen a patient experience respiratory depression even after receiving the standard dose." (R8) Staffing Gaps One notable theme that emerged from the interviews highlighted the impact of clinic workload on pain assessment and subsequent morphine prescription. A respondent reflected on this challenge, stating: "Sometimes, on a busy clinic day, people might not really go into detail asking, 'Do you have pain?' and then trying to assess the degree of it. I think, probably, if we did that better, we would get more patients on morphine." (R6) Facilitators to Morphine Use Perceived Effectiveness of Morphine Despite the barriers cited above, all respondents unanimously agreed on the significant utility of morphine in pain management, particularly among PLWH. The majority identified cryptococcal meningitis, herpes zoster, and cervical cancer as conditions frequently associated with moderate to severe pain, warranting morphine use. One respondent passionately described morphine as a “wonder drug” , stating: "It is a wonder drug. It provides relief within a very short time when prescribed at the right dose, and usually, there are very few side effects.” (R9) Another respondent echoed this sentiment: "A patient with controlled pain smiles, while a patient in pain frowns. Morphine has proven to be more useful than dangerous when properly administered and titrated to match the patient’s pain level." (R1) Similarly, another respondent emphasized its necessity: "Morphine is very useful for these patients because they suffer from conditions that cause not just pain, but severe pain.” (R6) Despite recognising morphine’s value, most respondents reported encountering only a few patients daily who required moderate to severe pain management. However, they expressed confidence in their ability to prescribe and administer morphine to PLWH. Their familiarity with the necessary procedures was evident, and they appeared well-equipped to manage the drug effectively in this context. One respondent exemplified this confidence, stating: "I am conversant with the drug. I know the entire drug profile of morphine, especially in HIV patients… In managing pain, I am completely comfortable.” (R3) Discussion The study identified three key barriers to morphine use: knowledge gaps, legal restrictions and opiophobia. These findings highlight both the challenges and facilitators associated with oral morphine use for pain relief in PLWH. Moreover, the study highlights the critical role of effective pain management in improving the quality of life for individuals living with HIV. Findings from the study further assert that pain from opportunistic infections such as cryptococcal meningitis, herpes zoster, and HIV-related cancers, as well as side effects from medications targeting these infections or HIV itself, is prevalent among patients[ 16 , 17 ]. This emphasises the need for effective pain control interventions among people living with HIV/AIDS. While clinicians were aware of morphine's primary role in treating moderate to severe pain, concerns regarding its safety, particularly for home use, were prevalent. Phillips JK, et al. (2017) highlights that this fear of morphine addiction is exacerbated by a lack of experience among some healthcare workers and misconceptions about the drug's risks [ 18 ]. However, some clinicians, particularly those who had more direct experience with morphine in both hospital and home settings, did not share these concerns, suggesting that increasing exposure to morphine use could mitigate such fears. These findings align with previous studies by Logie and Leng (2007), who emphasised the need for greater empowerment of healthcare workers in prescribing morphine to increase accessibility in underserved areas[ 13 ]. knowledge gap was identified as a key barrier to the optimal use of morphine for pain management. Clinicians emphasized the need for further training to improve their understanding of morphine administration, including appropriate dosing intervals and indications. This reflects a broader challenge where many healthcare workers, particularly newly recruited staff, have limited exposure to best practices in opioid prescribing. While CME sessions were highlighted as a valuable learning resource, discussions on morphine use often depend on whether a patient under review is receiving morphine, making the training case-specific rather than systematic. The WHO emphasises that continuous education at all levels is essential for scaling up palliative care [ 19 ]. Integrating structured opioid-focused training into routine healthcare education could provide a cost-effective strategy for enhancing access to essential pain relief [ 20 ]. While peer learning and case presentations help bridge some knowledge gaps, these opportunities are not uniformly accessible, highlighting the need for a standardized and comprehensive training framework across all healthcare cadres. This aligns with findings from previous studies that have identified limited knowledge on morphine use as a major barrier to its optimal prescription and accessibility for patients in need [ 21 , 22 ]. Addressing knowledge gaps is crucial for improving morphine accessibility and ensuring effective pain management, particularly in resource-limited settings like Uganda. Expanding prescriber training across various healthcare cadres could help mitigate the shortage of trained professionals, especially in rural areas where access to morphine remains constrained [ 23 – 25 ]. This strategy would not only facilitate the integration of pain management into routine care but also reduce the burden on specialized healthcare providers by broadening prescribing responsibilities. Strengthening policies to support opioid education and expanding the role of non-physician prescribers could further alleviate disparities in pain relief provision, ensuring that patients in underserved areas receive the care they need. Additionally, legal restrictions in the prescription of morphine, particularly the inconsistency in guidelines governing who is authorized to prescribe the medication was another barrier. While nurses and clinical officers play an essential role in outreach services and patient care[ 26 , 27 ], their inability to prescribe morphine in some settings due to legal restrictions limit patients' access to this vital medication. This restriction is particularly problematic in community-based care, where timely pain management is crucial for palliative patients, especially those with HIV related pain. Moreover, concerns about prescribing morphine to special populations add another layer of complexity. This might call for the need for more tailored approaches in pain management for paediatric patients, particularly those facing malnutrition, which may affect drug metabolism and efficacy[ 28 ]. These legal and clinical challenges point to a critical need for policy reform and tailored training for healthcare workers. Empowering healthcare providers, especially nurses and clinical officers, with the legal authority and skills to prescribe morphine could significantly improve access to pain relief, ultimately enhancing the quality of life for patients in resource-limited settings[ 8 – 10 ]. Additionally, adapting morphine prescribing guidelines for special populations would ensure safer and more effective pain management. The strong clinician consensus on morphine’s effectiveness emerged as a key facilitator in this study, aligning with existing literature that emphasises adequate pain control as essential for improving the quality of life in chronic and life-limiting conditions[ 29 ]. The WHO recognizes morphine as an essential medicine for palliative care and recommends it as the first-line opioid for managing moderate to severe pain [ 6 ]. Clinicians who have witnessed its effectiveness, particularly in terminally ill patients with cancer or HIV-related complications, are more likely to integrate it into routine pain management[ 13 ]. Studies indicate that healthcare providers who understand proper titration and risk mitigation strategies not only prescribe morphine more confidently but also help reduce unnecessary suffering[ 12 , 26 , 30 ]. Moreover, trust in morphine’s efficacy fosters stronger patient-provider relationships, enhancing adherence and reducing opioid-related stigma[ 7 ]. Expanding continuous medical education, hands-on training, and policy reforms can further strengthen clinician confidence, ensuring equitable access to pain relief. Strengths and limitations This qualitative study successfully identified previously undocumented barriers and facilitators to morphine prescriptions, reaching saturation with rich data before the targeted participant number. Interviews with specialists in both adult and paediatric medicine provided balanced perspectives in implementation of morphine across age groups. However, the study’s limitation included the time constraints during working hours, which may have affected the depth of responses. Although this study focused on HIV/AIDS care, the barriers and facilitators identified, including opiophobia, knowledge gaps, and regulatory constraints, are also relevant in other clinical settings within resource-limited environments. As such, the findings provide important insights that may be applicable to a broader range of conditions requiring pain management, such as cancer, and to similar healthcare systems struggling with opioid access and utilization. These insights have broader relevance for healthcare systems in low-resource settings facing similar challenges with opioid access and utilization. They can inform the development of comprehensive policies and training programs aimed at strengthening equitable and effective pain management across diverse clinical contexts. Conclusion This study identified knowledge gaps, legal restrictions, and opiophobia as key barriers to morphine prescription. However, clinicians' recognition of morphine’s essential role in pain relief and improving quality of life emerged as a key facilitator. Additionally, training healthcare workers who were initially not authorised to prescribe morphine, along with CME, are crucial factors in optimising morphine accessibility and effective pain management. To address these challenges, we recommend targeted training programs for healthcare workers, particularly those whose medical curricula do not empower morphine prescription. Expanding CME initiatives focused on dispelling misconceptions and enhancing clinical competencies in opioid use would help bridge knowledge gaps. Furthermore, strengthening policies and legal frameworks to expand prescriber roles would ensure equitable access to pain relief. Implementing these interventions would enhance clinical practices, particularly in resource-limited and community-based settings, ultimately reducing disparities in pain management and improving patient outcomes. Declarations Clinical trial number Not applicable Declarations Ethics approval and consent to participate: This study was conducted according to the Declaration of Helsinki. Ethical approval was obtained from the Hospice Africa Uganda Research and Ethics committee (HAUREc). Informed consent was obtained from all participants after providing a clear explanation of the study’s purpose and procedures. Participation was entirely voluntary, and participants were informed that they could withdraw at any time without consequence. Consent also included permission to publish anonymized responses and direct quotes. To ensure confidentiality, all data were anonymized, and pseudonyms were used throughout the analysis and reporting. Privacy and confidentiality were strictly maintained throughout the study, with audio recordings stored securely. Clinical trial number Not applicable Consent for publication: As part of the requirements for graduating with a Bachelor of Science in Palliative Care, a research dissertation was conducted in accordance with HAUREC guidelines and received the necessary approval. Competing interests: All authors have no competing interest to declare. Funding: This research did not receive any grant from funding agencies in the public, commercial, or not–for–profit sectors. Author Contribution CA conceived and designed the study as a lead author. CA, SN and BK did the data collection and interpretation. SN, BK, and EN participated in analysis. CA, SN, BK and EN participated in the interpretation of results and writing the final manuscript. All authors read and approved the final version of the manuscript. Acknowledgement The authors express their sincere gratitude to the hospital administrators and healthcare workers at Mildmay Uganda for granting permission and support to collect data from their facility. This work forms part of the bachelor’s thesis of Collins Ankunda, undertaken within the Bachelor of Science in Palliative Care program at Makerere University and the Institute of Hospice and Palliative Care in Africa. The authors extend special thanks to Dr. Jane Nakawesi for her invaluable assistance during data collection and to the International Association for Hospice and Palliative Care for their support throughout the bachelor’s program. Appreciation is also given to the Intent Health Research Group for their valuable input in shaping this manuscript. Data Availability Datasets for this work are available from the corresponding author upon reasonable request. References Bristowe K, Clift P, James R, Josh J, Platt M, et al. Towards person-centred care for people living with HIV: what core outcomes matter, and how might we assess them? A cross-national multi-centre qualitative study with key stakeholders. HIV Med. 2019;20:542–54. Parker R, Stein DJ, Jelsma J. Pain in people living with HIV/AIDS: a systematic review. J Int AIDS Soc. 2014;17:18719. Jeevanjee S, Penko J, Guzman D, Miaskowski C, Bangsberg DR, et al. Opioid analgesic misuse is associated with incomplete antiretroviral adherence in a cohort of HIV-infected indigent adults in San Francisco. AIDS Behav. 2014;18:1352–8. Cunningham CO. Opioids and HIV Infection: From Pain Management to Addiction Treatment. Top Antivir Med. 2018;25:143–6. Lewington J, Namukwaya E, Limoges J, Leng M, Harding R. Provision of palliative care for life-limiting disease in a low income country national hospital setting: how much is needed? BMJ Support Palliat Care. 2012;2:140–4. Safe access to morphine (n.d.). Available: https://www.who.int/our-work/access-to-medicines-and-health-products/controlled-substances/safe-access-to-morphine . Accessed 20 January 2025. Pain Education in Low-Resource Countries - International Association for the Study of Pain (IASP). Pain Education in Low-Resource Countries | IASP (n.d.). Int Assoc Study Pain IASP. Available: https://www.iasp-pain.org/resources/fact-sheets/pain-education-in-low-resource-countries/ . Accessed 20 January 2025. The. Morphine Keepers - Palliative care training in Uganda (n.d.). THET. Available: https://www.thet.org/stories/morphine-keepers-palliative-care-training-uganda/ . Accessed 20 January 2025. Downing J, Batuli M, Kivumbi G, Kabahweza J, Grant L, et al. A palliative care link nurse programme in Mulago Hospital, Uganda: an evaluation using mixed methods. BMC Palliat Care. 2016;15:40. Jagwe J, Merriman A. Uganda: Delivering Analgesia in Rural Africa: Opioid Availability and Nurse Prescribing. J Pain Symptom Manage. 2007;33:547–51. Nabudere H, Obuku E, Lamorde M. Advancing palliative care in the Uganda health system: an evidence-based policy brief. Int J Technol Assess Health Care. 2014;30:621–5. Reid CM, Gooberman-Hill R, Hanks GW. Opioid analgesics for cancer pain: symptom control for the living or comfort for the dying? A qualitative study to investigate the factors influencing the decision to accept morphine for pain caused by cancer. Ann Oncol. 2008;19:44–8. Logie D, Leng M. Africans die in pain because of fears of opiate addiction. BMJ. 2007;335:685–685. Coombs NC, Campbell DG, Caringi J. A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access. BMC Health Serv Res. 2022;22:438. Mildmay Uganda | Empowering Communities for Healthier Lives. (n.d.). Available: https://mildmay.or.ug/ . Accessed 24 April 2023. Azagew AW, Woreta HK, Tilahun AD, Anlay DZ. High prevalence of pain among adult HIV-infected patients at University of Gondar Hospital, Northwest Ethiopia. J Pain Res. 2017;10:2461–9. Rahatgaonkar A, Ali M, Ranka R, Dhar M, Kant R (n.d.) Cryptococcal Meningitis Presenting as Chronic Headache in an Apparently Immunocompetent Patient, editors. Cureus 15: e48668. National Academies of Sciences E, Division H, Policy M, on HS B, Abuse C, on PM, RS to APO, Phillips JK et al. (2017) Evidence on Strategies for Addressing the Opioid Epidemic. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. National Academies Press (US). Available: https://www.ncbi.nlm.nih.gov/books/NBK458653/ . Accessed 20 January 2025. Connor SR. (2020) Global Atlas of Palliative Care. Available: https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/palliative-care/whpca_global_atlas_p5_digital_final.pdf?sfvrsn=1b54423a_3 . Accessed 20 January 2025. Innab A, Alammar K, Alqahtani N, Aldawood F, Kerari A, et al. The impact of a 12-hour educational program on nurses’ knowledge and attitudes regarding pain management: a quasi-experimental study. BMC Nurs. 2022;21:250. Left Behind in Pain. Extent and Causes of Global Variations in Access to Morphine for Medical Use and Actions to Improve Safe Access. 1st ed. Geneva: World Health Organization; 2023. p. 1. Kweh T-Y, Yeoh C-H, Chan H-K, Ahmad F. Knowledge, Perception and Barriers to Cancer Pain Management among Doctors in Malaysia. Malays J Med Sci MJMS. 2023;30:184–94. Dambisya YM, Matinhure S. Policy and programmatic implications of task shifting in Uganda: a case study. BMC Health Serv Res. 2012;12:61. Ooms GI, van Oirschot J, de Kant D, van den Ham HA, Mantel-Teeuwisse AK, et al. Barriers to accessing internationally controlled essential medicines in sub-saharan Africa: A scoping review. Int J Drug Policy. 2023;118:104078. World Health Organization, PEPFAR, UNAIDS., (2007) Task shifting : rational redistribution of tasks among health workforce teams : global recommendations and guidelines: 88. Logie DE, Harding R. An evaluation of a morphine public health programme for cancer and AIDS pain relief in Sub-Saharan Africa. BMC Public Health. 2005;5:82. National Academies of Sciences, Medicine E, of NA et al. Nursing 2020–2030 C on the F of, Flaubert JL, Menestrel SL,. (2021) The Role of Nurses in Improving Health Care Access and Quality. The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity. National Academies Press (US). Available: https://www.ncbi.nlm.nih.gov/books/NBK573910/ . Accessed 20 January 2025. Krishnaswamy K. Drug Metabolism and Pharmacokinetics in Malnourished Children. Clin Pharmacokinet. 1989;17:68–88. Eyelade OR, Ajayi IO, Elumelu TN, Soyannwo OA, Akinyemi OA. Oral Morphine Effectiveness in Nigerian Patients With Advanced Cancer. J Pain Palliat Care Pharmacother. 2012;26:24–9. Horn DB, Vu L, Porter BR, Sarantopoulos K. (2025) Responsible Controlled Substance and Opioid Prescribing. StatPearls. Treasure Island (FL): StatPearls Publishing. Available: http://www.ncbi.nlm.nih.gov/books/NBK572085/ . Accessed 14 February 2025. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7240173","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":530643976,"identity":"1681e84e-bf10-4412-9241-5b4ee1776dba","order_by":0,"name":"Collins Ankunda","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYFACNihmZ244wMBgA2QxNh4gTgszI0hLGkhLA/FagORhsBheLfyz29KkC8rs5PmZGRsPF/w5b7e2/TDQlhqbaFxaJO4cOyY941yy4cxmxobDM9tuJ287kwjUciwttwGXnhvpbdK8bcwJBoeBWngbbiebHQBqAbJxapGHaKmHaOH5cy7Z7PxD/FoMbqQdA2o5DNXCdsDO7AYBWwxvpCVb85w7DvELb1tygtkNoC0JePwidyPN8DZPWbU8P3vz4c88f+zszc6nP3zwocYGt/fRQSJYZQKxykHAnhTFo2AUjIJRMDIAAAp2YlbcpzyJAAAAAElFTkSuQmCC","orcid":"","institution":"Makerere University","correspondingAuthor":true,"prefix":"","firstName":"Collins","middleName":"","lastName":"Ankunda","suffix":""},{"id":530643977,"identity":"a7bbbb63-0068-4d06-a903-d328e4e8aa65","order_by":1,"name":"Sharon Namasambi","email":"","orcid":"","institution":"Uganda Public Health Fellowship Program, Uganda National Institute of Public Health, Kampala, Uganda.","correspondingAuthor":false,"prefix":"","firstName":"Sharon","middleName":"","lastName":"Namasambi","suffix":""},{"id":530643978,"identity":"0bb73cd3-0823-4de1-af47-573f4fbfafb6","order_by":2,"name":"Brendah Kyomuhangi","email":"","orcid":"","institution":"Entebbe Regional Referral Hospital","correspondingAuthor":false,"prefix":"","firstName":"Brendah","middleName":"","lastName":"Kyomuhangi","suffix":""},{"id":530643979,"identity":"94202391-e32b-44a9-abac-85940fcc4f2a","order_by":3,"name":"Elizabeth Namukwaya","email":"","orcid":"","institution":"Makerere University","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Namukwaya","suffix":""}],"badges":[],"createdAt":"2025-07-29 07:23:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7240173/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7240173/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93770057,"identity":"8470be21-cac2-439f-ad42-4314f649a59b","added_by":"auto","created_at":"2025-10-17 11:39:14","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":76660,"visible":true,"origin":"","legend":"","description":"","filename":"RevisedCleanBarriersandFacilitatorstoMorphinePrescription05082025.docx","url":"https://assets-eu.researchsquare.com/files/rs-7240173/v1/8a5ef73d080dc3806f2640ba.docx"},{"id":93770056,"identity":"a844a689-dfdc-4131-a70c-d67a2ab9121a","added_by":"auto","created_at":"2025-10-17 11:39:14","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7283,"visible":true,"origin":"","legend":"","description":"","filename":"9c1595fcd1bd40de88be7137e9a6c2bf.json","url":"https://assets-eu.researchsquare.com/files/rs-7240173/v1/6d0162e03c9d8cd7e15f66b8.json"},{"id":93770061,"identity":"0aba29de-08ac-4a09-a64c-11d4acd1e219","added_by":"auto","created_at":"2025-10-17 11:39:15","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2864495,"visible":true,"origin":"","legend":"","description":"","filename":"RECApprovalLetter.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7240173/v1/9ff72348cbb1dc06bb8e1481.pdf"},{"id":93770062,"identity":"c9bbe230-4460-4053-a3a6-ea0052803d01","added_by":"auto","created_at":"2025-10-17 11:39:15","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":81096,"visible":true,"origin":"","legend":"","description":"","filename":"9c1595fcd1bd40de88be7137e9a6c2bf1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7240173/v1/90f575ca209a8e1a3da15cdd.xml"},{"id":93770289,"identity":"ed1b9202-2d5d-4140-a931-465693aeb3a6","added_by":"auto","created_at":"2025-10-17 11:47:14","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":79074,"visible":true,"origin":"","legend":"","description":"","filename":"9c1595fcd1bd40de88be7137e9a6c2bf1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7240173/v1/42c9769bd639d434989feab9.xml"},{"id":93770058,"identity":"8ae5a28a-e2d2-4077-990e-dd7d21c30681","added_by":"auto","created_at":"2025-10-17 11:39:14","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":88881,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7240173/v1/546f44ba082f530c21e64d32.html"},{"id":101734985,"identity":"b89f065a-1588-4f6b-94ba-7161e5382313","added_by":"auto","created_at":"2026-02-03 06:58:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":754996,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7240173/v1/bd7abf1b-b1a4-4078-8696-1ad0d802bb3e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers and Facilitators to Morphine Prescription Among Clinicians in Uganda: A Qualitative Study at Mildmay Uganda","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePain management is a critical component of medical care, particularly for individuals living with HIV/AIDS(PLWH), where effective pain relief can significantly improve quality of life[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Globally, up to 83% of people living with HIV (PLWH) experience moderate to severe pain, particularly in advanced stages of the disease, due to the direct effects of HIV, opportunistic infections, cancers, or antiretroviral therapy side effects. Despite this high burden, only 21–53% receive opioid prescriptions[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e–\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Although pain is widely recognized as a major concern in people living with HIV/AIDS, it often remains underdiagnosed and inadequately treated, particularly in resource-limited settings such as Uganda [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOral morphine, classified as an essential medicine by the World Health Organization (WHO), is the cornerstone for managing moderate to severe pain in palliative care[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Studies have demonstrated that morphine can be provided effectively, safely, and affordably, even in low-income settings[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Uganda has been recognized as a leader in palliative care in Africa, with innovations such as nurse-led morphine prescription and the integration of palliative care into its national health policy[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e–\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, the government’s reported opioid consumption remains critically low, meeting less than 10% of the estimated need [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This gap highlights systemic challenges that hinder the prescription and availability of morphine, leaving a substantial number of patients in pain without adequate treatment.\u003c/p\u003e\u003cp\u003eStudies done on morphine prescription have shown health workers’ reluctance to prescribe morphine as a significant barrier to its use[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Factors contributing to this reluctance include fears of side effects such as respiratory depression and addiction, limited training in opioid use, bureaucratic hurdles, and stigmatization of morphine as a “last-resort” treatment for the terminally ill[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These barriers are compounded by systemic challenges, including restrictive government policies, inadequate supply chains, and a shortage of trained prescribers. For instance, despite training efforts, many facilities lack accreditation to stock and dispense opioids, resulting in significant unmet needs among patients[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite Uganda's efforts to enhance morphine accessibility through expanded prescriber training and integrating palliative care into its health framework, many patients still endure unrelieved pain, reflecting global challenges in addressing under-treatment in HIV and cancer care[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Staff shortages, particularly in rural areas, limit access to trained providers, leaving many patients without adequate pain relief [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eInformal discussions with clinicians at Mildmay Uganda revealed persistent hesitancy in prescribing morphine, despite training, with only seven patients receiving it over three months. This contrasts sharply with the estimated need among people living with HIV/AIDS at the facility. Understanding barriers and enablers to morphine prescription is crucial for improving pain management, addressing disparities, and enhancing opioid use in low-resource settings. These findings contribute to the global agenda for equitable palliative care by informing strategies to overcome reluctance, improve access to essential pain medications, and advance pain relief for underserved populations.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis study employed a qualitative research design using thematic analysis to explore factors influencing morphine prescription among clinicians in Uganda, with a focus on Mildmay Uganda. The approach allowed for in-depth exploration of clinicians' experiences, concerns, and practices related to morphine use in the context of HIV care.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStudy Area\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eMildmay Uganda, established in 1998, is one of the leading HIV care and treatment facility in Uganda, serving as both a health provider and a research institution. The organization provides comprehensive HIV prevention, care, treatment, training, and research services in central Uganda. This study focuses on Mildmay Uganda, a prominent HIV care provider, which manages approximately over 5,000 patients monthly[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStudy Population\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThis study targeted clinicians actively involved in patient review and treatment at Mildmay Uganda. Participants included two specialists, seven medical officers, and two clinical officers who provided informed consent. Selection criteria focused on clinicians with prior training in morphine prescription and direct prescribing roles. However, those who met the criteria but were unavailable on the interview day were excluded.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSampling Techniques\u003c/strong\u003e\u003c/p\u003e\u003cp\u003ePurposeful sampling was employed to select participants who had relevant knowledge of morphine and were authorized to prescribe it. Specifically, the study focused on medical officers, clinical officers, and nurses who had completed a morphine prescriber’s course, ensuring they had the necessary understanding of how morphine works and when it is appropriate to prescribe. Recruitment continued until data saturation was achieved, where no new themes emerged from the data. The target sample size was 15 participants; however, the adequacy of the sample size was determined by the principal of data saturation rather than a fixed number. The study reached saturation with 11 participants, at which point no new themes emerged during data collection.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eData collection was conducted between March and April 2016 using a semi-structured interview guide developed in English by the study team. The guide was reviewed and refined based on feedback from the study supervisor and the ethical committee to ensure scientific rigor. Reliability was strengthened through a pilot study involving three different cadres of healthcare workers at Mildmay Uganda, with revisions made based on their feedback. The interview guide focused on key issues, including barriers to morphine prescription and associated challenges, allowing for a flexible yet structured exploration of participants' views and experiences. Open-ended questions with prompts facilitated in-depth and comprehensive responses, encouraging clinicians to freely express their concerns, fears, and insights regarding morphine use.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eEach respondent was assigned a unique identifier (R1–R11) to ensure confidentiality. To ensure anonymity and minimise identification bias, respondents were interviewed in a random sequence. Notably, all eleven clinicians accepted the invitation to participate, reflecting a shared willingness to discuss morphine use and its implications.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe study team consisted of four members, with two interviewers conducting the interviews (one to interview and the other to take notes) and two analysts leading the data analysis process. Thematic analysis was conducted manually. Transcripts were reviewed in a cyclical and reflexive process to ensure a thorough examination of the data. Audio recordings were first cross-checked against field notes to verify accuracy and completeness before transcription. Transcripts were then transcribed verbatim in English and independently reviewed by the two analysts to identify emerging themes. Each analyst developed a thematic framework separately, and the final themes were refined through the integration of these frameworks. This process allowed for cross-validation and reduced individual interpretation bias. To ensure data integrity and minimize human error, results at each stage of analysis were checked against the study’s research questions. The two interviewers also cross-validated the data to further enhance credibility. Separating the roles of data collection and analysis and incorporating cross-checking mechanisms, the study minimized subjectivity and optimized the reliability and validity of its findings.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eEleven respondents participated in this study, including two specialists who also served as heads of both adult and paediatric clinics, seven medical doctors, and two clinical officers. All of the respondents had served as clinicians for more than 2 years as shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipants\u0026rsquo; characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eUnique Identifier*\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDuration in Service in years\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDate of interview\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9th March 2016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9th March 2016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9th March 2016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9th March 2016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9th March 2016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9th March 2016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9th April 2016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6th April 2016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6th April 2016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7th April 2016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7th April 2016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*Note: \u0026ldquo;R\u0026rdquo; refers to the respondent, and the number denotes the corresponding interview.\u003c/p\u003e\u003cp\u003eThematic analysis of the in-depth interviews revealed three major themes: knowledge gaps, opiophobia, and legal restrictions. These themes encapsulate the key barriers and facilitators clinicians encountered in prescribing and administering oral morphine as presented in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e below.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and Subthemes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub-themes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge gap\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1. Inadequate Training on Morphine Prescription\u003c/p\u003e\u003cp\u003e2. Uncertainty in Dosing\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOpiophobia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1. Risk of addiction\u003c/p\u003e\u003cp\u003e2. Abuse of Opioids\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLegal restrictions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1. Restrictive Prescribing Regulations\u003c/p\u003e\u003cp\u003e2. Lack of prescription guidelines in special populations\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStaffing Gap\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1. Workload\u003c/p\u003e\u003cp\u003e2. Failure to Assess Pain\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerceived Effectiveness of Morphine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1. Rapid Pain Relief\u003c/p\u003e\u003cp\u003e2. Essential Role in HIV related pain management.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eKnowledge gaps\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMost respondents identified inadequate training as a major barrier to morphine prescription, emphasizing the need for additional training to enhance healthcare workers' competency and optimize morphine use.\u003c/p\u003e\u003cp\u003eOne of the respondents remarked:\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u0026ldquo;I think the challenge is people, many people have not been trained or probably they don\u0026rsquo;t have the right information, probably they don\u0026rsquo;t know how to use it. They may be prescribing 8 hourly or 6 hourly instead of 4 hourly, but otherwise, I feel that maybe that\u0026rsquo;s the major barrier to morphine use. But otherwise, it\u0026rsquo;s ok for me if used for the right purpose and properly, the right dose.\u003c/strong\u003e\u003cp\u003e(R5)\u003c/p\u003e\u003c/p\u003e\u003cp\u003eAdditionally, respondent R6 highlighted gaps in training, particularly for newly recruited staff:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;Maybe with the new staffs who we have not yet trained\u0026hellip; yeah, they might have different perceptions.\u0026rsquo;\u003c/em\u003e (R6)\u003c/p\u003e\u003cp\u003eWhile many clinicians cited inadequate training as a barrier to morphine prescription, some did not share this concern. One respondent highlighted the availability of Continuous Medical Education (CME) sessions, which offer regular learning opportunities.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;I should not say often we don\u0026rsquo;t often get it (training), but we have CMEs weekly, and if a topic came up regarding medication of a patient that entails morphine, normally we share information about morphine and other opioid treatment.\u0026rsquo; (R1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe respondent further suggested a practical approach to improving knowledge and practice among colleagues:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026lsquo;Maybe a way forward for colleagues to be knowledgeable is to have a case presentation on how different colleagues have managed pain because it is usually not common.\u0026rsquo; (R1)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eLegal restrictions\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Respondents identified key barriers to morphine prescription, including restrictive prescribing regulations, the absence of clear guidelines for special populations such as people living with HIV (PLWH), and inconsistencies across existing prescribing guidelines.\u003c/p\u003e\u003cp\u003eOne respondent remarked:\u003c/p\u003e\u003cp\u003e\u003cem\u003e \"Some guidelines might not allow nurses to prescribe, yet they are the ones conducting outreaches! For example, in organizations that provide outreach services to critically ill patients, I think they just need to be empowered to prescribe morphine.\"\u003c/em\u003e (R7)\u003c/p\u003e\u003cp\u003eSimilarly, respondent noted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"There are some nurses who have been trained on the ward, but they can only administer an initial dose. The doctor then has to step in and prescribe.\"\u003c/em\u003e (R6)\u003c/p\u003e\u003cp\u003eRegarding morphine prescription for special populations, particularly malnourished children living with HIV, a respondent from the paediatric department raised concerns about the standard morphine dose of 0.2 mg/kg body weight, questioning its appropriateness for this vulnerable group.\u003c/p\u003e\u003cp\u003eThe respondent noted:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"That dose of 0.2... is not favourable at all. The universal dose of 0.2 mg/kg oral morphine really does not suit malnourished children. I am not sure whether there are alternative guidelines specifically addressing morphine prescription in malnourished patients.\"\u003c/em\u003e (R3)\u003c/p\u003e\u003cp\u003e\u003cb\u003eOpiophobia.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eRespondents highlighted concerns about addiction, opioid misuse, and other side effects as key barriers to morphine prescription. One respondent expressed particular concern about prescribing morphine to outpatients, emphasizing the risk of addiction due to potential non-adherence to prescribed dosages.\u003c/p\u003e\u003cp\u003eOne respondent stated:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"What I fear most is addiction, especially for outpatients. If you prescribe morphine, say a bottle, and instruct them to take 5 mL, they might go home and take 10 mL instead, knowing it provides relief. Over time, as they increase the dose, they risk becoming addicted and may seek it from other sources.\"\u003c/em\u003e (R2)\u003c/p\u003e\u003cp\u003eSimilarly, another respondent from the adult outpatient clinic highlighted concerns about respiratory depression as a serious adverse effect:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"What we fear most with morphine is respiratory depression, primarily when someone receives a higher-than-normal dose. However, I have occasionally seen a patient experience respiratory depression even after receiving the standard dose.\"\u003c/em\u003e (R8)\u003c/p\u003e\u003cp\u003e\u003cb\u003eStaffing Gaps\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOne notable theme that emerged from the interviews highlighted the impact of clinic workload on pain assessment and subsequent morphine prescription. A respondent reflected on this challenge, stating:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Sometimes, on a busy clinic day, people might not really go into detail asking, 'Do you have pain?' and then trying to assess the degree of it. I think, probably, if we did that better, we would get more patients on morphine.\" (R6)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eFacilitators to Morphine Use\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePerceived Effectiveness of Morphine\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDespite the barriers cited above, all respondents unanimously agreed on the significant utility of morphine in pain management, particularly among PLWH. The majority identified cryptococcal meningitis, herpes zoster, and cervical cancer as conditions frequently associated with moderate to severe pain, warranting morphine use.\u003c/p\u003e\u003cp\u003eOne respondent passionately described morphine as a \u003cem\u003e\u0026ldquo;wonder drug\u0026rdquo;\u003c/em\u003e, stating:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"It is a wonder drug. It provides relief within a very short time when prescribed at the right dose, and usually, there are very few side effects.\u0026rdquo;\u003c/em\u003e (R9)\u003c/p\u003e\u003cp\u003eAnother respondent echoed this sentiment:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"A patient with controlled pain smiles, while a patient in pain frowns. Morphine has proven to be more useful than dangerous when properly administered and titrated to match the patient\u0026rsquo;s pain level.\"\u003c/em\u003e (R1)\u003c/p\u003e\u003cp\u003eSimilarly, another respondent emphasized its necessity:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Morphine is very useful for these patients because they suffer from conditions that cause not just pain, but severe pain.\u0026rdquo;\u003c/em\u003e (R6)\u003c/p\u003e\u003cp\u003eDespite recognising morphine\u0026rsquo;s value, most respondents reported encountering only a few patients daily who required moderate to severe pain management. However, they expressed confidence in their ability to prescribe and administer morphine to PLWH. Their familiarity with the necessary procedures was evident, and they appeared well-equipped to manage the drug effectively in this context.\u003c/p\u003e\u003cp\u003eOne respondent exemplified this confidence, stating:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I am conversant with the drug. I know the entire drug profile of morphine, especially in HIV patients\u0026hellip; In managing pain, I am completely comfortable.\u0026rdquo;\u003c/em\u003e (R3)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study identified three key barriers to morphine use: knowledge gaps, legal restrictions and opiophobia. These findings highlight both the challenges and facilitators associated with oral morphine use for pain relief in PLWH. Moreover, the study highlights the critical role of effective pain management in improving the quality of life for individuals living with HIV. Findings from the study further assert that pain from opportunistic infections such as cryptococcal meningitis, herpes zoster, and HIV-related cancers, as well as side effects from medications targeting these infections or HIV itself, is prevalent among patients[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This emphasises the need for effective pain control interventions among people living with HIV/AIDS.\u003c/p\u003e\u003cp\u003eWhile clinicians were aware of morphine's primary role in treating moderate to severe pain, concerns regarding its safety, particularly for home use, were prevalent. Phillips JK, et al. (2017) highlights that this fear of morphine addiction is exacerbated by a lack of experience among some healthcare workers and misconceptions about the drug's risks [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, some clinicians, particularly those who had more direct experience with morphine in both hospital and home settings, did not share these concerns, suggesting that increasing exposure to morphine use could mitigate such fears. These findings align with previous studies by Logie and Leng (2007), who emphasised the need for greater empowerment of healthcare workers in prescribing morphine to increase accessibility in underserved areas[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eknowledge gap was identified as a key barrier to the optimal use of morphine for pain management. Clinicians emphasized the need for further training to improve their understanding of morphine administration, including appropriate dosing intervals and indications. This reflects a broader challenge where many healthcare workers, particularly newly recruited staff, have limited exposure to best practices in opioid prescribing. While CME sessions were highlighted as a valuable learning resource, discussions on morphine use often depend on whether a patient under review is receiving morphine, making the training case-specific rather than systematic. The WHO emphasises that continuous education at all levels is essential for scaling up palliative care [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Integrating structured opioid-focused training into routine healthcare education could provide a cost-effective strategy for enhancing access to essential pain relief [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. While peer learning and case presentations help bridge some knowledge gaps, these opportunities are not uniformly accessible, highlighting the need for a standardized and comprehensive training framework across all healthcare cadres. This aligns with findings from previous studies that have identified limited knowledge on morphine use as a major barrier to its optimal prescription and accessibility for patients in need [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAddressing knowledge gaps is crucial for improving morphine accessibility and ensuring effective pain management, particularly in resource-limited settings like Uganda. Expanding prescriber training across various healthcare cadres could help mitigate the shortage of trained professionals, especially in rural areas where access to morphine remains constrained [\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This strategy would not only facilitate the integration of pain management into routine care but also reduce the burden on specialized healthcare providers by broadening prescribing responsibilities. Strengthening policies to support opioid education and expanding the role of non-physician prescribers could further alleviate disparities in pain relief provision, ensuring that patients in underserved areas receive the care they need.\u003c/p\u003e\u003cp\u003e Additionally, legal restrictions in the prescription of morphine, particularly the inconsistency in guidelines governing who is authorized to prescribe the medication was another barrier. While nurses and clinical officers play an essential role in outreach services and patient care[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], their inability to prescribe morphine in some settings due to legal restrictions limit patients' access to this vital medication. This restriction is particularly problematic in community-based care, where timely pain management is crucial for palliative patients, especially those with HIV related pain. Moreover, concerns about prescribing morphine to special populations add another layer of complexity. This might call for the need for more tailored approaches in pain management for paediatric patients, particularly those facing malnutrition, which may affect drug metabolism and efficacy[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. These legal and clinical challenges point to a critical need for policy reform and tailored training for healthcare workers. Empowering healthcare providers, especially nurses and clinical officers, with the legal authority and skills to prescribe morphine could significantly improve access to pain relief, ultimately enhancing the quality of life for patients in resource-limited settings[\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Additionally, adapting morphine prescribing guidelines for special populations would ensure safer and more effective pain management.\u003c/p\u003e\u003cp\u003eThe strong clinician consensus on morphine\u0026rsquo;s effectiveness emerged as a key facilitator in this study, aligning with existing literature that emphasises adequate pain control as essential for improving the quality of life in chronic and life-limiting conditions[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The WHO recognizes morphine as an essential medicine for palliative care and recommends it as the first-line opioid for managing moderate to severe pain [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Clinicians who have witnessed its effectiveness, particularly in terminally ill patients with cancer or HIV-related complications, are more likely to integrate it into routine pain management[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Studies indicate that healthcare providers who understand proper titration and risk mitigation strategies not only prescribe morphine more confidently but also help reduce unnecessary suffering[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Moreover, trust in morphine\u0026rsquo;s efficacy fosters stronger patient-provider relationships, enhancing adherence and reducing opioid-related stigma[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Expanding continuous medical education, hands-on training, and policy reforms can further strengthen clinician confidence, ensuring equitable access to pain relief.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStrengths and limitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis qualitative study successfully identified previously undocumented barriers and facilitators to morphine prescriptions, reaching saturation with rich data before the targeted participant number. Interviews with specialists in both adult and paediatric medicine provided balanced perspectives in implementation of morphine across age groups. However, the study\u0026rsquo;s limitation included the time constraints during working hours, which may have affected the depth of responses. Although this study focused on HIV/AIDS care, the barriers and facilitators identified, including opiophobia, knowledge gaps, and regulatory constraints, are also relevant in other clinical settings within resource-limited environments. As such, the findings provide important insights that may be applicable to a broader range of conditions requiring pain management, such as cancer, and to similar healthcare systems struggling with opioid access and utilization. These insights have broader relevance for healthcare systems in low-resource settings facing similar challenges with opioid access and utilization. They can inform the development of comprehensive policies and training programs aimed at strengthening equitable and effective pain management across diverse clinical contexts.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study identified knowledge gaps, legal restrictions, and opiophobia as key barriers to morphine prescription. However, clinicians' recognition of morphine\u0026rsquo;s essential role in pain relief and improving quality of life emerged as a key facilitator. Additionally, training healthcare workers who were initially not authorised to prescribe morphine, along with CME, are crucial factors in optimising morphine accessibility and effective pain management.\u003c/p\u003e\u003cp\u003eTo address these challenges, we recommend targeted training programs for healthcare workers, particularly those whose medical curricula do not empower morphine prescription. Expanding CME initiatives focused on dispelling misconceptions and enhancing clinical competencies in opioid use would help bridge knowledge gaps. Furthermore, strengthening policies and legal frameworks to expand prescriber roles would ensure equitable access to pain relief. Implementing these interventions would enhance clinical practices, particularly in resource-limited and community-based settings, ultimately reducing disparities in pain management and improving patient outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eClinical trial number\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eDeclarations\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003cp\u003e This study was conducted according to the Declaration of Helsinki. Ethical approval was obtained from the Hospice Africa Uganda Research and Ethics committee (HAUREc). Informed consent was obtained from all participants after providing a clear explanation of the study\u0026rsquo;s purpose and procedures. Participation was entirely voluntary, and participants were informed that they could withdraw at any time without consequence. Consent also included permission to publish anonymized responses and direct quotes. To ensure confidentiality, all data were anonymized, and pseudonyms were used throughout the analysis and reporting. Privacy and confidentiality were strictly maintained throughout the study, with audio recordings stored securely.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003cp\u003e As part of the requirements for graduating with a Bachelor of Science in Palliative Care, a research dissertation was conducted in accordance with HAUREC guidelines and received the necessary approval.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests:\u003c/h2\u003e\u003cp\u003eAll authors have no competing interest to declare.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis research did not receive any grant from funding agencies in the public, commercial, or not\u0026ndash;for\u0026ndash;profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCA conceived and designed the study as a lead author. CA, SN and BK did the data collection and interpretation. SN, BK, and EN participated in analysis. CA, SN, BK and EN participated in the interpretation of results and writing the final manuscript. All authors read and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors express their sincere gratitude to the hospital administrators and healthcare workers at Mildmay Uganda for granting permission and support to collect data from their facility. This work forms part of the bachelor\u0026rsquo;s thesis of Collins Ankunda, undertaken within the Bachelor of Science in Palliative Care program at Makerere University and the Institute of Hospice and Palliative Care in Africa. The authors extend special thanks to Dr. Jane Nakawesi for her invaluable assistance during data collection and to the International Association for Hospice and Palliative Care for their support throughout the bachelor\u0026rsquo;s program. Appreciation is also given to the Intent Health Research Group for their valuable input in shaping this manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDatasets for this work are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBristowe K, Clift P, James R, Josh J, Platt M, et al. Towards person-centred care for people living with HIV: what core outcomes matter, and how might we assess them? A cross-national multi-centre qualitative study with key stakeholders. HIV Med. 2019;20:542\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eParker R, Stein DJ, Jelsma J. Pain in people living with HIV/AIDS: a systematic review. J Int AIDS Soc. 2014;17:18719.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJeevanjee S, Penko J, Guzman D, Miaskowski C, Bangsberg DR, et al. Opioid analgesic misuse is associated with incomplete antiretroviral adherence in a cohort of HIV-infected indigent adults in San Francisco. AIDS Behav. 2014;18:1352\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCunningham CO. Opioids and HIV Infection: From Pain Management to Addiction Treatment. Top Antivir Med. 2018;25:143\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLewington J, Namukwaya E, Limoges J, Leng M, Harding R. Provision of palliative care for life-limiting disease in a low income country national hospital setting: how much is needed? BMJ Support Palliat Care. 2012;2:140\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSafe access to morphine (n.d.). Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/our-work/access-to-medicines-and-health-products/controlled-substances/safe-access-to-morphine\u003c/span\u003e\u003cspan address=\"https://www.who.int/our-work/access-to-medicines-and-health-products/controlled-substances/safe-access-to-morphine\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 January 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePain Education in Low-Resource Countries - International Association for the Study of Pain (IASP). Pain Education in Low-Resource Countries | IASP (n.d.). Int Assoc Study Pain IASP. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.iasp-pain.org/resources/fact-sheets/pain-education-in-low-resource-countries/\u003c/span\u003e\u003cspan address=\"https://www.iasp-pain.org/resources/fact-sheets/pain-education-in-low-resource-countries/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 January 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThe. Morphine Keepers - Palliative care training in Uganda (n.d.). THET. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.thet.org/stories/morphine-keepers-palliative-care-training-uganda/\u003c/span\u003e\u003cspan address=\"https://www.thet.org/stories/morphine-keepers-palliative-care-training-uganda/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 January 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDowning J, Batuli M, Kivumbi G, Kabahweza J, Grant L, et al. A palliative care link nurse programme in Mulago Hospital, Uganda: an evaluation using mixed methods. BMC Palliat Care. 2016;15:40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJagwe J, Merriman A. Uganda: Delivering Analgesia in Rural Africa: Opioid Availability and Nurse Prescribing. J Pain Symptom Manage. 2007;33:547\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNabudere H, Obuku E, Lamorde M. Advancing palliative care in the Uganda health system: an evidence-based policy brief. Int J Technol Assess Health Care. 2014;30:621\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReid CM, Gooberman-Hill R, Hanks GW. Opioid analgesics for cancer pain: symptom control for the living or comfort for the dying? A qualitative study to investigate the factors influencing the decision to accept morphine for pain caused by cancer. Ann Oncol. 2008;19:44\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLogie D, Leng M. Africans die in pain because of fears of opiate addiction. BMJ. 2007;335:685\u0026ndash;685.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCoombs NC, Campbell DG, Caringi J. A qualitative study of rural healthcare providers\u0026rsquo; views of social, cultural, and programmatic barriers to healthcare access. BMC Health Serv Res. 2022;22:438.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMildmay Uganda | Empowering Communities for Healthier Lives. (n.d.). Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://mildmay.or.ug/\u003c/span\u003e\u003cspan address=\"https://mildmay.or.ug/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 24 April 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAzagew AW, Woreta HK, Tilahun AD, Anlay DZ. High prevalence of pain among adult HIV-infected patients at University of Gondar Hospital, Northwest Ethiopia. J Pain Res. 2017;10:2461\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRahatgaonkar A, Ali M, Ranka R, Dhar M, Kant R (n.d.) Cryptococcal Meningitis Presenting as Chronic Headache in an Apparently Immunocompetent Patient, editors. Cureus 15: e48668.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Academies of Sciences E, Division H, Policy M, on HS B, Abuse C, on PM, RS to APO, Phillips JK et al. (2017) Evidence on Strategies for Addressing the Opioid Epidemic. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. National Academies Press (US). Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK458653/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK458653/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 January 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eConnor SR. (2020) Global Atlas of Palliative Care. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/palliative-care/whpca_global_atlas_p5_digital_final.pdf?sfvrsn=1b54423a_3\u003c/span\u003e\u003cspan address=\"https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/palliative-care/whpca_global_atlas_p5_digital_final.pdf?sfvrsn=1b54423a_3\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 January 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eInnab A, Alammar K, Alqahtani N, Aldawood F, Kerari A, et al. The impact of a 12-hour educational program on nurses\u0026rsquo; knowledge and attitudes regarding pain management: a quasi-experimental study. BMC Nurs. 2022;21:250.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeft Behind in Pain. Extent and Causes of Global Variations in Access to Morphine for Medical Use and Actions to Improve Safe Access. 1st ed. Geneva: World Health Organization; 2023. p. 1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKweh T-Y, Yeoh C-H, Chan H-K, Ahmad F. Knowledge, Perception and Barriers to Cancer Pain Management among Doctors in Malaysia. Malays J Med Sci MJMS. 2023;30:184\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDambisya YM, Matinhure S. Policy and programmatic implications of task shifting in Uganda: a case study. BMC Health Serv Res. 2012;12:61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOoms GI, van Oirschot J, de Kant D, van den Ham HA, Mantel-Teeuwisse AK, et al. Barriers to accessing internationally controlled essential medicines in sub-saharan Africa: A scoping review. Int J Drug Policy. 2023;118:104078.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization, PEPFAR, UNAIDS., (2007) Task shifting : rational redistribution of tasks among health workforce teams : global recommendations and guidelines: 88.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLogie DE, Harding R. An evaluation of a morphine public health programme for cancer and AIDS pain relief in Sub-Saharan Africa. BMC Public Health. 2005;5:82.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Academies of Sciences, Medicine E, of NA et al. Nursing 2020\u0026ndash;2030 C on the F of, Flaubert JL, Menestrel SL,. (2021) The Role of Nurses in Improving Health Care Access and Quality. The Future of Nursing 2020\u0026ndash;2030: Charting a Path to Achieve Health Equity. National Academies Press (US). Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK573910/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK573910/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 20 January 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrishnaswamy K. Drug Metabolism and Pharmacokinetics in Malnourished Children. Clin Pharmacokinet. 1989;17:68\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEyelade OR, Ajayi IO, Elumelu TN, Soyannwo OA, Akinyemi OA. Oral Morphine Effectiveness in Nigerian Patients With Advanced Cancer. J Pain Palliat Care Pharmacother. 2012;26:24\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHorn DB, Vu L, Porter BR, Sarantopoulos K. (2025) Responsible Controlled Substance and Opioid Prescribing. StatPearls. Treasure Island (FL): StatPearls Publishing. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/books/NBK572085/\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/books/NBK572085/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 14 February 2025.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Morphine prescription, Pain management, Barriers and facilitators, Uganda","lastPublishedDoi":"10.21203/rs.3.rs-7240173/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7240173/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003ePain management is a critical component of palliative care, particularly for HIV/AIDS and cancer patients. Despite oral morphine being an essential medication for treating moderate to severe pain, its accessibility and utilization remain suboptimal in many resource-limited settings. This study explored the barriers and facilitators to morphine prescription at Mildmay Uganda (Mug) to provide actionable insights for improving pain management practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA qualitative study design was employed, involving semi-structured interviews with clinicians. 11 clinicians were purposively sampled based on their experience with morphine prescription and administration between March to April 2016. Data were analyzed thematically to identify key barriers and facilitators influencing morphine use in clinical practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThree primary barriers to morphine use were identified: opiophobia, knowledge gaps, and legal restrictions. Opiophobia was driven by concerns about addiction and adverse effects, particularly in home-based care settings. Knowledge gaps were highlighted among newly recruited staff and those without formal training, leading to inconsistencies in dosing practices. Legal restrictions, including limited prescriber authorization, further constrained access to morphine, particularly in community-based care. A key facilitator was the strong clinician consensus on morphine’s effectiveness in pain management, which enhanced confidence in its use and encouraged broader adoption in clinical practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003e\u0026nbsp;While clinicians acknowledge morphine’s effectiveness in pain relief, its use is hindered by opiophobia, knowledge gaps, and restrictive policies. However, strong clinician consensus on its benefits enhances confidence in prescribing. Targeted training and continuous medical education (CME) are essential to addressing misconceptions and improving competency. Strengthening policies to expand prescriber roles and integrating structured CME into routine practice can enhance clinical outcomes, reduce disparities, and ensure equitable access to pain relief, particularly in resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Barriers and Facilitators to Morphine Prescription Among Clinicians in Uganda: A Qualitative Study at Mildmay Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 11:39:10","doi":"10.21203/rs.3.rs-7240173/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"847ee93f-e85a-4fb5-9a39-c84c8c0607a8","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-03T06:56:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 11:39:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7240173","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7240173","identity":"rs-7240173","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}